Evidence based diagnosis and management of chronic subdural hematoma: A review of the literature

A Case Report of Tranexamic Acid for the Treatment of Chronic Subdural Hematoma in an 86-Year-Old Patient

Fibrinolytic and coagulative hyperactivity is proven to have a role in liquefaction and progression of chronic subdural hematoma (CSDH). Tranexamic acid was one of the pharmaceutical options that was explored, as it inhibits the hyper-fibrinolytic activity and reduces the vascular permeability in CSDH, leading to a gradual resolution of the hematoma. In this case study, we present a case of using tranexamic acid for CSDH treatment in an 86-year-old patient with co-morbidities. The complete resolution of the hematoma following using tranexamic acid in this case with no history of recurrence in two years follow-up supports its efficacy in CSDH treatment and may be considered as one of the strategies that help prevent surgeries.

Comparative analysis of surgical techniques in the management of chronic subdural hematomas and risk factors for poor outcomes

Chronic subdural hematomas (CSDH) are increasingly prevalent, especially among the elderly. Surgical intervention is essential in most cases. However, the choice of surgical technique, either craniotomy or burr-hole opening, remains a subject of debate. Additionally, the risk factors for poor long-term outcomes following surgical treatment remain poorly described. This article presents a 10-year retrospective cohort study conducted at a single center that aimed to compare the outcomes of two common surgical techniques for CSDH evacuation: burr hole opening and minicraniotomy. The study also identified risk factors associated with poor long-term outcome, which was defined as an mRS score ≥ 3 at 6 months. This study included 582 adult patients who were surgically treated for unilateral CSDH. Burr-hole opening was performed in 43% of the patients, while minicraniotomy was performed in 57%. Recurrence was observed in 10% of the cases and postoperative complications in 13%. The rates of recurrence, postoperative complications, death and poor long-term outcome did not differ significantly between the two surgical approaches. Multivariate analysis identified postoperative general complications, recurrence, and preoperative mRS score ≥ 3 as independent risk factors for poor outcomes at 6 months. Recurrence contribute to a poorer prognosis in CSDH. Nevertheless, use burr hole or minicraniotomy for the management of CSDH showed a similar recurrence rate and no significant differences in post-operative outcomes. This underlines the need for a thorough assessment of patients with CSHD and the importance of avoiding their occurrence, by promoting early mobilization of patients. Future research is necessary to mitigate the risk of recurrence, regardless of the surgical technique employed.

Relative Cortical Atrophy Index as a Strong Predictor of Recurrence After Surgery for Chronic Subdural Hematoma

BACKGROUND AND OBJECTIVES

Chronic subdural hematoma (CSDH) presents significant management challenges in neurosurgical practice, with recurrence being a notable postoperative consideration. This study aimed to evaluate the Relative Cortical Atrophy (RCA) Index as a predictor of recurrence after CSDH surgery.

METHODS

A retrospective analysis was conducted on 98 patients who underwent surgical evacuation for unilateral CSDH. The RCA Index was calculated using pre- and postoperative cranial imaging, correlating it with patient demographics, hematoma characteristics, and recurrence. Inter-rater reliability among measurements by 4 independent physicians was assessed using the intraclass correlation coefficient (ICC). Correlation and regression analyses were performed to identify the correlation of the RCA Index with other factors and their potential predicting power of CSDH recurrence, respectively.

RESULTS

The study population had a mean age of 74.1 (11.9) years, with a 23.5% (23 patients) recurrence rate of CSDH. The ICC analysis showed excellent inter-rater reliability for RCA Index measurements (ICC: 0.998, 95% CI: 0.997-0.998, P < .001). A higher preoperative RCA Index was significantly associated with recurrence (0.215 [0.031] in the recurrent group vs 0.125 [0.034] in the nonrecurrent group, P < .001). The preoperative RCA Index highly correlated with the postoperative RCA Index (Pearson's correlation: 0.918, P < .001), and there was only a small (average: 0.005) but significant increase in the RCA Index of the unaffected hemisphere after surgery (P = .01).The preoperative RCA Index positively correlated with age, preoperative SDH thickness and volume, and recurrence. A RCA Index cutoff value of 0.165 predicted CSDH recurrence with high sensitivity (95.6%) and specificity (93.3%) (area under the curve = 0.97, 95% CI: 0.93-1).

CONCLUSION

The RCA Index is a simple yet robust predictor of CSDH recurrence. Incorporating this measure into the preoperative assessment may enhance surgical planning and postoperative management, potentially reducing recurrence rates.

Middle meningeal artery embolization reduces recurrence following surgery for septated chronic subdural hematomas

BACKGROUND

Septated chronic subdural hematomas (cSDH) have high rates of recurrence despite surgical evacuation. Middle meningeal artery embolization (MMAE) has emerged as a promising adjuvant for secondary prevention, yet its efficacy remains ill-defined.

METHODS

This is a retrospective review of septated cSDH cases treated at our institution. The surgery-only group was derived from cases performed before 2018, and the surgery+MMAE group was derived from cases performed 2018 or later. The primary outcome was reoperation rate. Secondary outcomes were recurrence, change in hematoma thickness, and midline shift.

RESULTS

A total of 34 cSDHs in 28 patients (surgery+MMAE) and 95 cSDHs in 83 patients (surgery-only) met the inclusion criteria. No significant difference in baseline characteristics between groups was identified. The reoperation rate was significantly higher in the surgery-only group (n = 16, 16.8%) compared with the surgery+MMAE cohort (n = 0, 0.0%) (p=0.006). A reduced incidence of recurrence (p=0.011) was also seen in the surgery+MMAE group.

CONCLUSIONS

MMAE for septated cSDH was found to be highly effective in preventing recurrence and reoperation. MMAE is an adjunct to surgical evacuation may be of particular benefit in this patient cohort.

Mortality Predictors for Adult Patients with Mild-to-Moderate Traumatic Brain Injury: A Literature Review

Traumatic brain injuries (TBIs) represent a significant public health concern, with mild-to-moderate cases comprising a substantial portion of incidents. Understanding the predictors of mortality among adult patients with mild-to-moderate TBIs is crucial for optimizing clinical management and improving outcomes. This literature review examines the existing research to identify and analyze the mortality predictors in this patient population. Through a comprehensive review of peer-reviewed articles and clinical studies, key prognostic factors, such as age, Glasgow Coma Scale (GCS) score, the presence of intracranial hemorrhage, pupillary reactivity, and coexisting medical conditions, are explored. Additionally, this review investigates the role of advanced imaging modalities, biomarkers, and scoring systems in predicting mortality following a mild-to-moderate TBI. By synthesizing the findings from diverse studies, this review aims to provide clinicians and researchers with valuable insights into the factors influencing mortality outcomes in adult patients with a mild-to-moderate TBI, thus facilitating more informed decision making and targeted interventions in clinical practice.

Delayed Manifestation of Massive Bilateral Sub-acute Subdural Hemorrhage

Sub-acute subdural hematoma (SASDH) in the elderly is a challenging diagnosis given its insidious onset and nonspecific presentation, particularly following minor head trauma. This case report highlights the clinical features, diagnostic challenges, and management of SASDH in an elderly patient. A 72-year-old male presented with a five-day history of giddiness, headache, and balance issues, which began suddenly without a significant triggering event. His medical history was notable only for a minor fall approximately one month before presentation, after which he experienced no immediate or significant symptoms. An MRI at an outside hospital revealed bilateral frontoparietotemporal SASDHs with diffuse cerebral edema. The patient underwent a bilateral mini craniotomy for hematoma evacuation and was managed postoperatively with anti-seizure medications and supportive care, resulting in a satisfactory outcome. The diagnosis of SASDH requires a high index of suspicion, especially in the elderly, who may present with vague and progressive symptoms following minor head trauma. Early and accurate diagnosis via imaging, particularly MRI, is crucial for effective management. Surgical intervention, typically involving hematoma evacuation, significantly improves outcomes in patients with SASDH, underscoring the importance of timely surgical referral and treatment. Elderly patients presenting with unexplained neurological symptoms following even minor trauma should be evaluated for SASDH. Early recognition and intervention are crucial to prevent long-term morbidity and mortality in this vulnerable population.

Single-Center Comparison of Chronic Subdural Hematoma Evacuation Outcomes Under Local Versus General Anesthesia

BACKGROUND

Chronic subdural hematoma (CSDH) is a neurosurgical pathology of an aged populace. Pathogenetic risk factors include traumatic brain injury, prolonged use of antiplatelet drugs, hypertension, and some inflammatory processes. The incidence increases as patients age. Burr-hole evacuation is the most common approach in management of symptomatic cases. We compared evacuation of chronic subdural hematomas with general or local anesthesia (GA and LA, respectively) and evaluated the safety, economic benefits, effects of comorbidity, benefits, and shortcomings of both techniques.

METHODS

We conducted a retrospective study of 67 consecutive patients who had 74 procedures for CSDH in a single neurosurgical center, the Regional Clinic, Centre of Neurosurgery and Neurology, over a 3-year period. They were grouped into the GA group (n = 44) and LA group (n = 23). Mean duration of procedure, length of hospital stay, complications, and preoperative and postoperative neurologic statuses were compared. The distribution of nominal variables between groups was compared using the Fisher exact test. The average duration of operation and length of hospital stay were compared using the Mann-Whitney U-test due to violation of the normality assumption.

RESULTS

LA proved to be as effective as GA in CSDH evacuation. Seventy-four surgical procedures were performed on 67 patients due to recurrence in less than 30 days in 7 patients. Fifteen patients had tension pneumocephalus managed with fluid therapy to full recovery. LA was economical and required shorter hospital stays and surgical time.

CONCLUSIONS

In our studies, LA proved to be noninferior to GA, time conserving, and less prone to some of the adverse effects of GA on elderly patients with comorbidity, although some patients who are hyperactive or contraindicated to LA will require GA.

Neovascularization in Outer Membrane of Chronic Subdural Hematoma : A Rationale for Middle Meningeal Artery Embolization

OBJECTIVE

Chronic subdural hematomas (cSDHs) are generally known to result from traumatic tears of bridging veins. However, the causes of repeat spontaneous cSDHs are still unclear. We investigated the changes in vasculature in the human dura mater and outer membrane (OM) of cSDHs to elucidate the cause of their spontaneous repetition.

METHODS

The dura mater was obtained from a normal control participant and a patient with repeat spontaneous cSDHs. The pathological samples from the patient included the dura mater and OM tightly adhered to the inner dura. The samples were analyzed with a particular focus on blood and lymphatic vessels by immunohistochemistry, 3-dimensional imaging using a transparent tissue clearing technique, and electron microscopy.

RESULTS

The dural border cell (DBC) layer of the dura mater and OM were histologically indistinguishable. There were 5.9 times more blood vessels per unit volume of tissue in the DBC layer and OM in the patient than in the normal control. The DBC layer and OM contained pathological sinusoidal capillaries not observed in the normal tissue; these capillaries were connected to the middle meningeal arteries via penetrating arteries. In addition, marked lymphangiogenesis in the periosteal and meningeal layers was observed in the patient with cSDHs.

CONCLUSION

Neovascularization in the OM seemed to originate from the DBC layer; this is a potential cause of repeat spontaneous cSDHs. Embolization of the meningeal arteries to interrupt the blood supply to pathological capillaries via penetrating arteries may be an effective treatment option.

In vitro comparison of middle meningeal artery embolization with Squid liquid embolic agent and Contour polyvinyl alcohol particles

BACKGROUND

Liquid embolic agents and polyvinyl alcohol (PVA) particles have been used for the embolization of the middle meningeal artery (MMA) for the treatment of chronic subdural hematomas. However, the vascular penetration and distribution of these embolic agents have not yet been compared. The current study compares distribution of a liquid embolic agent (Squid) to PVA particles (Contour) in an in vitro model of the MMA.

METHODS

MMA models were embolized with Contour PVA particles 45-150 µm, Contour PVA particles 150-250 µm, and Squid-18 liquid embolic agent (n=5 each). The models were scanned and every vascular segment with embolic agent was manually marked on the images. Embolized vascular length as a percentage of control, average embolized vascular diameter, and embolization time were compared between the groups.

RESULTS

The 150-250 µm Contour particles primarily accumulated close to the microcatheter tip, yielding proximal branch occlusions. The 45-150 µm Contour particles achieved a more distal distribution, but in a patchy segmental pattern. However, the models embolized with Squid-18 had a consistently distal, near-complete and homogenous distribution. Embolized vascular length was significantly higher (76±13% vs 5±3%, P=0.0007) and average embolized vessel diameter was significantly smaller (405±25 µm vs 775±225 µm, P=0.0006) with Squid than with Contour. Embolization time with Squid was also lower (2.8±2.4 min vs 6.4±2.7 min, P=0.09).

CONCLUSIONS

Squid-18 liquid results in a considerably more consistent, distal and homogeneous pattern of embolysate distribution than Contour PVA particles in an anatomical model of the MMA tree.

Intraoperative Irrigation and Risk of Chronic Subdural Hematoma Recurrence

BACKGROUND AND OBJECTIVES

In most neurosurgical centers, irrigation is an essential part of the surgical procedure for chronic subdural hematoma (CSDH). However, it is unknown whether the volume of irrigation fluid affects the risk of CSDH recurrence. This study aimed to investigate a potential association between the volume of irrigation fluid used during burr hole evacuation of CSDH and the risk of CSDH recurrence.

METHODS

This study is a subanalysis of 2 randomized trials (Drain Time & Drain Time 2) designed to investigate the effect of drainage duration on the recurrence of CSDH. Intraoperative irrigation volume was measured, and patients were followed for 90 days for recurrent CSDH.

RESULTS

A total of 525 patients with CSDH were included. There was no significant difference in the volume of irrigation fluid used between patients with recurrence (mean = 938 mL, SD = ±552) and without recurrence (mean = 852 mL, SD = ±454) ( P -value = .15). Patients with recurrent CSDH had larger primary CSDH volumes (mean = 134 cm 3 , SD = ±69) than patients without recurrence (mean = 119 cm 3 , SD = ±58) ( P = .04). Multiple logistic regression analysis revealed no association between irrigation volume and recurrence, also when stratified for hematoma size.

CONCLUSION

There was no significant association between irrigation volume and recurrent CSDH within 90 days in patients undergoing burr hole surgery for CSDH.

Adjuvant Tranexamic Acid for Reducing Postoperative Recurrence of Chronic Subdural Hematoma in the Elderly: A Systematic Review and Meta-Analysis

BACKGROUND

Chronic subdural hematoma (CSDH) is a frequently encountered neurosurgical disease among the elderly. The mainstay treatment involves surgical evacuation, but recurrence rates of approximately 13% pose complications. Adjuvant treatments, including tranexamic acid (TXA), have been explored, yet consensus on their efficacy and safety in elderly patients remains uncertain. The study aims to examine the role of TXA as adjunctive therapy in reducing CSDH recurrence and explore any potential association between TXA use and thrombotic events in this patient population.

METHODS

The systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane Handbook standards, searching databases up to July 2023 for randomized controlled trials and propensity-matched cohorts evaluating adjuvant TXA. The primary outcome was CSDH recurrence, and the secondary outcome was thrombosis risk, measured as relative risks.

RESULTS

A total of 6 studies were included, comprising 1403 patients with CSDH who underwent surgical treatment. Four studies were randomized controlled trials, while the other 2 were propensity-matched cohorts. The overall pooled relative risk for CSDH recurrence in the TXA group compared to the control group was 0.41 (95% confidence interval [0.29-0.59], P < 0.01), indicating a significant reduction in recurrence with TXA treatment.

CONCLUSIONS

In conclusion, our study indicates that adjuvant TXA may help reduce CSDH recurrence in elderly patients undergoing surgical treatment. However, the study has limitations and there is a need for further research to validate these findings.

Immediate procedural safety of adjunctive proximal coil occlusion in middle meningeal artery embolization for chronic subdural hematomas: Experience in 137 cases

BACKGROUND

Endovascular embolization of the middle meningeal artery (MMA) has emerged as an adjunctive and stand-alone modality for the management of chronic subdural hematomas (cSDH). We report our experience utilizing proximal MMA coil embolization to augment cSDH devascularization in MMA embolization.

METHODS

MMA embolization cases with adjunctive proximal MMA coiling were retrospectively identified from a prospectively maintained IRB-approved database of the senior authors.

RESULTS

Of the 137 cases, all patients (n = 89, 100%) were symptomatic and underwent an MMA embolization procedure for cSDH. 50 of the patients underwent bilateral embolizations, with 53% (n = 72) for left-sided and 47% (n = 65) for right-sided cSDH. The anterior MMA branch was embolized in 19 (14%), posterior in 16 (12%), and both in 102 (74.5%) cases. Penetration of the liquid embolic to the contralateral MMA or into the falx was present in 38 (28%) and 31 (23%) cases, respectively, and 46 (34%) cases had ophthalmic or petrous collateral (n = 41, 30%) branches. MMA branches coiled include the primary trunk (25.5%, n = 35), primary and anterior or posterior MMA trunks (20%, n = 28), or primary with the anterior and posterior trunks (54%, n = 74). A mild ipsilateral facial nerve palsy was reported, which remained stable at discharge and follow-up. Absence of anterograde flow in the MMA occurred in 137 (100%) cases, and no cases required periprocedural rescue surgery for cSDH evacuation. The average follow-up length was 170 ± 17.9 days, cSDH was reduced by 4.24 ± 0.5(mm) and the midline shift by 1.46 ± 0.27(mm). Complete resolution was achieved in 63 (46.0%) cases.

CONCLUSION

Proximal MMA coil embolization is a safe technique for providing additional embolization/occlusion of the MMA in cSDH embolization procedures. Further studies are needed to evaluate the potential added efficacy of this technique.

LC-MS-based urine metabolomics analysis of chronic subdural hematoma for biomarker discovery

BACKGROUND

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases with atypical manifestations. The aim of this study was to utilize urine metabolomics to explore potential biomarkers for the diagnosis and prognosis of CSDH.

METHODS

Seventy-seven healthy controls and ninety-two patients with CSDH were enrolled in our study. In total, 261 urine samples divided into the discovery group and validation group were analyzed by LC-MS. The statistical analysis and functional annotation were applied to discover potential biomarker panels and altered metabolic pathways.

RESULTS

A total of 53 differential metabolites were identified in this study. And the urinary metabolic profiles showed apparent separation between patients and controls. Further functional annotation showed that the differential metabolites were associated with lipid metabolism, fatty acid metabolism, amino acid metabolism, biotin metabolism, steroid hormone biosynthesis, and pentose and glucuronate interconversions. Moreover, one panel of Capryloylglycine, cis-5-Octenoic acid, Ethisterone, and 5,6-DiHETE showed good predictive performance in the diagnosis of CSDH, with an AUC of 0.89 in discovery group and an AUC of 0.822 in validation group. Another five metabolites (Trilobinol, 3'-Hydroxyropivacaine, Ethisterone, Arginyl-Proline, 5-alpha-Dihydrotestosterone glucuronide) showed the levels of them returned to a healthy state after surgery, showing good possibility to monitor the recovery of CSDH patients.

CONCLUSION AND CLINICAL RELEVANCE

The findings of the study revealed urine metabolomic differences between CSDH and controls. The potentially diagnostic and prognostic biomarker panels of urine metabolites were established, and functional analysis demonstrated deeper metabolic disorders of CSDH, which might conduce to improve early diagnose of CSDH clinically.

The distance between the falx cerebri and the corpus callosum in patients with bilateral subdural hematomas: A potential measure of disease severity

BACKGROUND

We aimed to assess the usefulness of the falx cerebri and the corpus callosum measurements as imaging markers of the evaluation of patients with bilateral subdural hematomas.

METHODS

The anterior-posterior and craniocaudal distances between the falx cerebri (FC) and the corpus callosum (CC) were retrospectively measured in 88 head CT scans from 2018 to 2022 from patients with bilateral subdural hematomas and associated with quantitative data and clinical outcomes. Statistical analysis was performed using multivariate regression and receiver operating characteristic curves.

RESULTS

Of the 88 patients included, 77.3% were male and the median age of 76.0 years (interquartile range 14.0). The mean craniocaudal and anterior-posterior FC-CC distances were 27.6 ± 6.2 mm and 25.1 ± 6.9 mm, respectively, and showed a positive correlation with hematoma thickness and volume. Both anterior-posterior and craniocaudal FC-CC distances exhibited moderate to good inter-rater reliability. After adjusting for confounders, the craniocaudal FC-CC distance was associated with an increased risk of altered consciousness at admission (OR=1.013; 95% CI 1.001-1.024; p = 0.031), downward displacement of the third ventricle (OR=1.019; 95% CI 1.001-1.038; p = 0.035), and a reduced time to surgery (β = 0.057; 95% CI 0.007-0.107; p = 0.027).

CONCLUSION

This study emphasizes that increased FC-CC distances in patients with bilateral subdural hematomas may aid clinical decision-making and are associated with larger hematoma volumes, evidence of descending transtentorial herniation on imaging, and a heightened risk of altered consciousness at admission.

Patient perception and satisfaction in awake burr hole trepanation under local anesthesia for evacuation of chronic subdural hematoma

Evacuation of chronic subdural hematoma (CSDH) will be one of the most common neurosurgical procedures in the future in the increasingly aging societies. Performing cranial surgery on awake patients may place a psychological burden on them. Aim of this study was to evaluate the psychological distress of patients during awake CSDH relief. Patients with awake evacuation of CSDH via burr hole trepanation were included in our monocentric prospective study. Patient perception and satisfaction were measured using standardized surveys 3-5 days and 6 months after surgery. Among other questionnaires, the Hospital Anxiety and Depression and the Impact of Event Scale, were used to quantify patients' stress. A total of 50 patients (mean age 72.9 years (range 51 - 92)) were included. During surgery, 28 patients reported pain (mean 4.1 (SD 3.3)). Postoperatively, 26 patients experienced pain (mean 2.7 (SD 2.6)). Patients' satisfaction with intraoperative communication was reported with a mean of 8.3 (SD 2.1). There was a significant negative correlation between intraoperatively perceived pain and satisfaction with intraoperative communication (p = 0.023). Good intraoperative communication during evacuation of CSDH in awake patients is associated with positive patient perception and correlates with pain reduction.

Efficacy and safety of steroids for chronic subdural hematoma: A systematic review and meta-analysis

Background

Chronic subdural hematoma (CSDH) is a condition characterized by the accumulation of fluid, blood, and blood breakdown products between the brain's arachnoid and dura mater coverings. While steroids have been explored as a potential treatment option, their efficacy and safety remain uncertain. This meta-analysis and systematic review aimed to assess the impact of steroids on CSDH management, including mortality, recurrence, complications, and functional outcomes.

Methods

We conducted a comprehensive literature search in major electronic databases up to June 2023, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane Handbook for Systematic Reviews and Interventions. Inclusion criteria encompassed adult patients with CSDH, the use of steroids as monotherapy or adjuvant therapy, and clearly defined outcomes. Randomized controlled trials and cohort studies meeting these criteria were included in the study.

Results

The initial search yielded 4315 articles, with 12 studies meeting the inclusion criteria. Our findings indicate a non-significant trend toward reduced mortality with steroids in combination with standard care (Odds ratios [OR] = 0.66, 95% confidence interval [CI] 0.20-2.18). However, substantial heterogeneity was observed (I2 = 70%). Sensitivity analysis, excluding influential studies, suggested a potential increased mortality risk associated with steroids (OR = 1.47, 95% CI 0.87-2.48). Steroids showed a possible benefit in reducing the recurrence of CSDH (OR = 0.58, 95% CI 0.20-1.67), but with significant heterogeneity (I2 = 89%). No clear advantage of steroids was observed in terms of functional outcomes at three months (modified Rankin scale scores). Furthermore, steroids were associated with a significantly higher incidence of adverse effects and complications (OR = 2.17, 95% CI 1.48-3.17).

Conclusion

Steroids may have a potential role in reducing CSDH recurrence but do not appear to confer significant advantages in terms of mortality or functional outcomes. However, their use is associated with a higher risk of adverse effects and complications. Given the limitations of existing studies, further research is needed to refine the role of steroids in CSDH management, considering patient-specific factors and treatment protocols.

Middle Meningeal Artery Embolization versus Surgery in Patients with Chronic Subdural Hematoma-No More Fence Sitting?

BACKGROUND

Endovascular treatment of patients with chronic subdural hematoma using middle meningeal artery (MMA) embolization could become an alternative to surgical hematoma evacuation. The aim of the study was to compare methods and identify parameters to help determine the correct treatment modality.

METHODS

We retrospectively reviewed 142 cases conducted internally; 78 were treated surgically and 64 were treated using MMA embolization. We analyzed the treatment failure rate and complications, and using a binary logistic regression model, we identified treatment failure risk factors.

RESULTS

We found a comparable treatment failure rate of 23.1% for the surgery group and 21.9% for the MMA embolization group. However, in the MMA embolization group, 11 cases showed treatment failure due to early neurological worsening with a need for concomitant surgery. We also found a recurrence of hematoma in 15.4% of cases in the surgery group and 6.3% of cases in the MMA embolization group.

CONCLUSION

Both modalities have their advantages; however, correct identification is crucial for treatment success. According to our findings, hematomas with a maximal width of <18 mm, a midline shift of <5 mm, and no acute or subacute (hyperdense) hematoma could be treated with MMA embolization. Hematomas with a maximal width of >18 mm, a midline shift of >5 mm, and no membranous segmentation could have better outcomes after surgical treatment.

Bilateral posterior fossa chronic subdural hematoma as a cause of hydrocephalus

Background

Infratentorial chronic subdural hematoma (cSDH) is still a rather elusive neurosurgical entity, which, due to its proximity and likely compression of the cerebellum and brainstem, can lead to devastating consequences. To establish standardized treatment, more studies and reports regarding its therapy are needed. We report a case of a simultaneous unilateral supratentorial and bilateral infratentorial cSDH, with the latter causing hydrocephalus and successfully treated with a bilateral burr-hole trepanation of occipital bone and placement of subdural drains.

Case Description

A 71-year-old man with gait disturbance, Glasgow Coma Scale 12, and a radiologically verified unilateral supratentorial and bilateral cSDH of the posterior fossa causing cerebellum, brainstem, and fourth ventricle compression with obstructive hydrocephalus, underwent surgical evacuation of infratentorial hematoma with a bilateral burr-hole trepanation. The postoperative course was uneventful, with a control head computed tomography scan showing the resolution of the hematoma and hydrocephalus. The patient was discharged with no newly acquired neurological deficits.

Conclusion

Due to a limited number of reports and studies involving infratentorial cSDHs causing hydrocephalus, decision-making and optimal surgical treatment remain unclear. We recommend a timely surgical evacuation of the hematoma if the patient is symptomatic while avoiding placement of external ventricular drainage.

Clinical Reasoning: An Older Woman With Headaches and Lethargy After a Fall

In this case, a 77-year-old woman presented with generalized weakness, difficulty ambulating, lethargy, loss of appetite, and headaches after a mechanical fall. This case discusses the management of acute neurologic emergencies such as subdural hematoma, status epilepticus, and bacterial meningitis. Potential etiologies for stroke and CNS infection are highlighted. Readers are led through the diagnostic approach to a patient presenting with a complex array of neurologic symptoms causing rapid clinical decompensation.

Middle Meningeal Artery Embolization Combined With Endoscopic Treatment for Chronic Subdural Hematoma

OBJECTIVE

To explore the clinical feasibility of middle meningeal artery (MMA) embolization combined with endoscopic treatment for new or recurrent chronic subdural hematoma (CSDH).

METHODS

Twenty patients with CSDH treated in the Binzhou Medical University Hospital from June 2020 to October 2022 were analyzed retrospectively. The clinical information, prognosis, imaging results, and surgical results of the patients were collected and analyzed. The authors first performed MMA embolization, and then endoscopic treatment of CSDH was performed after successful embolization of MMA. Results: All 20 patients with CSDH were successfully treated with MMA embolization combined with endoscope-assisted evacuation. The symptoms of all patients were relieved, no surgical complications occurred, and no rebleeding and recurrence were found in follow-up computed tomography.

CONCLUSION

Middle meningeal artery embolization combined with endoscopic treatment of CSDH has a good clinical effect, and it may prevent postoperative recurrence.

Administration of Tranexamic Acid After Burr Hole Craniotomy Reduced Postoperative Recurrence of Chronic Subdural Hematoma in a Japanese Regional Population

BACKGROUND

Although tranexamic acid (TXA) has occasionally been used to prevent postoperative recurrence of chronic subdural hematoma (CSDH) after burr hole craniotomy (BC), robust evidence of its efficacy has been lacking.

OBJECTIVE

To assess the efficacy and safety of postoperative oral administration of TXA after BC for CSDH among the elderly.

METHODS

This retrospective, propensity score-matched cohort study was carried out with a large Japanese local population-based longitudinal cohort in the Shizuoka Kokuho Database between April 2012 and September 2020. Patients included were age 60 years or older and had undergone BC for CSDH but were not undergoing dialysis. Covariates were collected from records of the preceding 12 months from the month of first BC, and patients were followed up for 6 months after surgery. The primary outcome was repeat surgery, and the secondary outcome was death or the onset of thrombosis. Data on postoperative TXA administration were collected and compared with controls using propensity score matching.

RESULTS

Of the 8544 patients who underwent BC for CSDH, 6647 were included, with 473 placed in the TXA group and 6174 placed in the control group. After 1:1 matching, repeated BC was found to have been performed in 30 of 465 patients (6.5%) in the TXA group and in 78 of 465 patients (16.8%) in the control group (relative risk, 0.38; 95% CI, 0.26-0.56). No significant difference was observed for death or the onset of thrombosis.

CONCLUSION

Oral administration of TXA reduced the occurrence of repeat surgery after BC for CSDH.

Risk factors for recurrence of chronic subdural hematoma after surgical evacuation: a systematic review and meta-analysis

Chronic subdural hematoma (CSDH) is a common neurosurgical condition. Surgical evacuation has remained the primary treatment despite many advancements in the endovascular field. Regardless, recurrence requiring reoperation is commonly observed during the postoperative follow-up. Herein, we aimed to investigate risk factors for recurrence after surgical evacuation. A review of MEDLINE, EMBASE, Web of Science, and Scopus was conducted using the designed search string. Studies were reviewed based on the predefined eligibility criteria. Data regarding sixty potential risk factors along with operational information were extracted for analysis. A meta-analysis using the random-effect model was conducted, and each risk factor affecting the postoperative recurrence of CSDH was then evaluated and graded. A total of 198 records met the eligibility criteria. A total number of 8523 patients with recurrent CSDH and 56,096 with non-recurrent CSDH were included in the study. The recurrence rate after surgical evacuation was 12%. Fifteen preoperative, nine radiologic, four hematoma-related, and three operative and postoperative factors were associated with recurrence. Risk factors associated with recurrence after surgical evacuation are important in neurosurgical decision-making and treatment planning. Found risk factors in this study may be used as the basis for pre-operative risk assessment to choose patients who would benefit the most from surgical evacuation.

Application of deep learning models for detection of subdural hematoma: a systematic review and meta-analysis

BACKGROUND

This study aimed to investigate the application of deep learning (DL) models for the detection of subdural hematoma (SDH).

METHODS

We conducted a comprehensive search using relevant keywords. Articles extracted were original studies in which sensitivity and/or specificity were reported. Two different approaches of frequentist and Bayesian inference were applied. For quality and risk of bias assessment we used Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2).

RESULTS

We analyzed 22 articles that included 1,997,749 patients. In the first step, the frequentist method showed a pooled sensitivity of 88.8% (95% confidence interval (CI): 83.9% to 92.4%) and a specificity of 97.2% (95% CI 94.6% to 98.6%). In the second step, using Bayesian methods including 11 studies that reported sensitivity and specificity, a sensitivity rate of 86.8% (95% CI: 77.6% to 92.9%) at a specificity level of 86.9% (95% CI: 60.9% to 97.2%) was achieved. The risk of bias assessment was not remarkable using QUADAS-2.

CONCLUSION

DL models might be an appropriate tool for detecting SDHs with a reasonably high sensitivity and specificity.

Efficacy of atorvastatin administration after surgery in patients with chronic subdural hematoma

To explore the clinical efficacy of atorvastatin administration after surgery in patients with chronic subdural hematoma. We conducted a retrospective study to analyze the clinical data of patients with chronic subdural hematoma. Patients receiving atorvastatin treatment after surgery were divided into the study group while others were divided into the control group. As the primary outcome, we compared the hematoma recurrence rate. The secondary outcomes were the remaining volume of hematoma and the activities of daily living (Barthel index) score at 3 months after discharge. A total of 53 patients were included in the study: 30 patients in the study group (n = 30) and 23 patients in the control group (n = 23). The baseline clinical data were similar in the 2 groups (P > .05). Four patients had recurrence of hematoma in the study group, while 5 patients had recurrence of hematoma in the control group [4/30 (13.3%) versus 5/23 (21.7%), P = .661] at 3 months after discharge. The mean remaining volume of hematoma was 12.10 ± 8.80 mL in the study group and 17.30 ± 9.50 mL in the control group at 3 months after discharge, respectively. The remaining volume of hematoma in the study group was less than that in the control group (P = .045).The activities of daily living score in the study group were higher than those in the control group (97.83 ± 4.48 vs 94.78 ± 5.73, P = .034) at 3 months after discharge. Atorvastatin administration after surgery barely reduce the recurrence rate of chronic subdural hematoma, however, reduced the remaining volume of hematoma and improved neurological function.

Nontraumatic subdural hematoma in patients on hemodialysis with end-stage kidney disease: a systematic review and pooled analysis

Background

The original treatment may aggravate when hemodialysis (HD) patients have nontraumatic subdural hematoma (NSDH). End-stage kidney disease patients are at increased risk for NSDH, but its risk factors and outcomes are not sufficiently explored at present.

Methods

Electronic databases, including PubMed, EMBASE, and Web of Science were searched by using various combinations of the keywords "Hemodialysis," "Renal Insufficiency," "Extracorporeal Dialysis," "Subdural Hematoma," "Subdural Hemorrhage," "Subdural Hematomas," and "Subdural Hemorrhages" in accordance with the PRISMA guidelines. Sixteen papers were selected. Relevant patient data were extracted, aggregated, and analyzed.

Results

A total of 74 patients were analyzed, including 37 male, 26 female, and 11 with no gender data, with a mean age of 56 years (range, 16-81 years). There were 43 patients with hypertension, 36 patients with diabetes, 16 patients who used oral anticoagulants before dialysis, and 10 patients with atrial fibrillation. The diagnosis of subdural hematoma (SDH) was made by computed tomography (CT) (n = 51), carotid arteriography (n = 7), surgical exploration (n = 3), and autopsy (n = 2). Forty cases underwent surgical treatment, including craniotomy and burr hole (or twist drill) drainage. The 1 year mortality rate of NSDH was 45.9%. The mortality rate after conservative treatment (61.8%) was higher than that after surgical intervention (32.5%). The mortality rate of NSDH in dialysis patients with atrial fibrillation and in those who used oral anticoagulants before hemodialysis (HD) was 90 and 81%, respectively.

Conclusion

NSDH is rare in HD, and mortality is high if NSDH occurs in dialysis patients. Surgical intervention reduces the mortality from NSDH in patients on HD (p < 0.02). Patients with atrial fibrillation and those who were taking oral anticoagulants before dialysis have a higher NSDH mortality (p < 0.01).

A systematic review of middle meningeal artery embolization for minimally symptomatic chronic subdural haematomas that do not require immediate evacuation

Introduction

Embolization of the Middle Meningeal Artery (EMMA) is an emerging treatment option for patients with Chronic Subdural Haematoma (CSDH).

Questions

(1) Can EMMA change the natural history of untreated minimally symptomatic CSDH which do not require immediate evacuation? (2) What is the role of EMMA in the prevention of recurrence following surgical treatment? (3) Can the procedure be performed under local anaesthetic?

Material and methods

Systematic literature review. No randomised clinical trials available on EMMA for meta-analysis.

Results

Six unique large cohorts with more than 50 embolisations were identified (evidence: 3b-4). EMMA can control the progression of surgically naïve CSDH in 91.1-100% of the patients, in which haematoma expansion is halted, or the lesion decreases and resolves. Treatment failure requiring surgery occurs in 0-4.1% of the patients having EMMA as the primary and only treatment. Treatment failure requiring surgery goes up slightly to 6.8% if post-surgical patients are included. When EMMA is used as postsurgical adjunctive the risk of recurrence is 1.4-8.9% compared to 10-20% in surgical series. EMMA has minimal morbidity and it is feasible under local anaesthesia or slight sedation in the majority of cases.

Conclusion

There is cumulative low-quality evidence in the literature that EMMA may be able to modify the natural course of the disease. It appears effective in controlling progression of CSDHs in patients having it as a primary standing alone treatment and it reduces the risk of recurrence and the need for surgical intervention in refractory postsurgical cases or as a postsurgical adjunctive treatment with minimal morbidity (recommendation: C).

Successful Management of Acute Promyelocytic Leukemia in a Patient Who Presented With Acute Ischemic Stroke on Top of Subdural Hematoma

Acute promyelocytic leukemia (APL), a distinct subtype of acute myelogenous leukemia (AML), is commonly associated with a heightened risk of bleeding due to coagulopathy. Thrombotic events, although less frequent, have also been linked to APL. However, the occurrence of ischemic stroke as an initial presentation of APL, particularly concomitant with central nervous system (CNS) bleeding, is exceedingly rare. The combination of these two complications is not reported in APL patients and is anticipated to carry a high mortality rate even with treatment. In this report, we describe the case of a young female patient with no significant medical history, who presented with decreased consciousness and recurrent seizures. Brain magnetic resonance imaging (MRI) revealed the simultaneous occurrence of acute ischemic stroke and acute-on-chronic subdural hematoma. The subsequent bone marrow biopsy confirmed the diagnosis of APL, displaying the characteristic positive promyelocytic leukemia (PML)-retinoic acid receptor alpha (RARA) t(15;17) translocation. The patient was promptly initiated on a high-risk AML-M3 protocol, coupled with supportive treatment through platelet transfusion. Remarkably, a favorable response to treatment was observed, and a marked improvement in her neurological parameters was observed within 2 weeks duration of treatment. Subsequent assessment through a bone marrow biopsy one month later revealed complete remission, with the PML-RARA fusion gene becoming negative following a single course of consolidation therapy.

Medical Management of Chronic Subdural Hematoma

Chronic subdural hematoma (CSDH) is a commonly encountered disease in the field of neurosurgery, typically resulting from head trauma. Several medical treatments have been introduced to manage patients with CSDH though surgical drainage is the main strategy to manage symptomatic patients. This review is aimed to meticulously examine contemporary pharmacological approaches, based on a thorough understanding of CSDH pathophysiology. Finally, the review offers a glance into future perspectives to enhance the management of CSDH.

Factors Associated With Short-Term Outcomes of Burr-Hole Craniostomy Associated With Brain Re-Expansion and Subdural Hematoma Shrinkage for Chronic Subdural Hematoma

Objective

Chronic subdural hematoma (CSDH) is a commonly encountered neurosurgical pathology that frequently requires surgical intervention. With an increasingly aging demographic, more older people and patients with comorbidities will present with symptomatic CSDH. This study evaluated clinical and laboratory factors affecting the short-term outcomes of CSDH after surgical intervention.

Methods

We retrospectively analyzed 170 patients who underwent burr-hole trephination for CSDH in a single institution from January 2019 to December 2021. All patients were examined for risk factors and evaluated for hematoma thickness change and midline shifting on brain computed tomography (CT) scans at 3 days after burr-hole trephination.

Results

This consecutive series of patients included 114 males (67.1%) and 56 females (32.9%); mean age 72.4±12.5 years. Renal disease (p=0.044) and prior intracranial hemorrhage (p=0.004) were clinical factors associated with poorer prognosis. A statistically significant association was found between initial laboratory findings, including high creatine kinase (p=0.025) and low platelet (p=0.036) levels, and CT findings 3 days postoperatively. The 3-day mean arterial pressure and postoperative ambulation were not significantly associated with outcomes.

Conclusion

Burr-hole craniostomy is an effective surgical procedure for initial CSDH. However, patients with a history intracranial hemorrhage and abnormal laboratory findings, such as low platelet levels, who underwent burr-hole trephination had poor short-term outcomes. Therefore, these patients should be carefully monitored.

Comparison of different surgical techniques for chronic subdural hematoma: a network meta-analysis

Background

Chronic subdural hematoma (CSDH) is a neurosurgical condition with high prevalence. Many surgical approaches are recommended for treating CSDH, but there needs to be a consensus on the optimal technique. This network meta-analysis (NMA) compared the efficacy and safety of different surgical treatments for CSDH.

Methods

Electronic databases, including PubMed, Embase, and the Cochrane Library, were searched for relevant studies up to February 2023. An NMA was performed to compare the outcomes of patients with CSDH treated by single-hole or double-hole craniotomy (SBHC and DBHC, respectively), twist-drill craniotomy (TDC), mini-craniotomy, and craniotomy. The NMA protocol was registered at INPLASY (registration no. 202320114).

Results

The NMA included 38 studies with 7,337 patients. For efficacy outcomes, DBHC showed the highest surface under the cumulative ranking area (SUCRA) values for recurrence (96.3%) and reoperation (87.4%) rates. DBHC differed significantly from mini-craniotomy in recurrence rate (odds ratio [OR] = 0.58, 95% confidence interval [CI]: 0.35, 0.97) and from SBHC (OR = 0.48, 95% CI: 0.25, 0.91) and TDC (OR = 0.40, 95% CI: 0.20, 0.82) in reoperation rate. For operative time, TDC was superior to SBHC (mean difference [MD] = -2.32, 95% CI: -3.78 to -0.86), DBHC (MD = -3.61, 95% CI: -5.55, -1.67), and mini-craniotomy (MD = -3.39, 95% CI: -5.70, -1.08). Patients treated by TDC had a shorter hospital stay than those treated by SBHC (MD = -0.82, 95% CI: -1.51, -0.12). For safety outcomes, there were no significant differences between groups in mortality and complication rates; however, mini-craniotomy (79.8%) and TDC (78.1%) had the highest SUCRAs.

Conclusion

DBHC may be the most effective surgical treatment for CSDH based on the low recurrence and reoperation rates, although all examined techniques were relatively safe.

Systematic review registration

https://inplasy.com/inplasy-2023-2-0114/.

Non-surgical patient characteristics best predict outcome after 6 months in patients surgically treated for chronic subdural haematoma

BACKGROUND

Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome 6 months after surgery.

METHODS

Retrospective data were collected on patients in Orebro County, Sweden, who had undergone surgery for CSDH at the Orebro University Hospital between 2013 and 2019. The outcomes were defined as favourable or unfavourable in terms of the modified Rankin Scale (mRS). A favourable outcome was defined as either mRS 0-2 or an unchanged mRS score in patients scoring 3-5 before surgery. From the variables in the data collected, a multiple logistic regression model was constructed.

RESULTS

The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88.

CONCLUSION

CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system.

UNSTRUCTURED ABSTRACT

Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome, in terms of the modified Rankin Scale (mRS), 6 months after surgery. The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88. In conclusion, CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system.

Coexistence of ipsilateral acute-on-chronic subdural hematoma and acute extradural hematoma: A case report

Chronic subdural hematomas are typically observed in elderly patients receiving antithrombotic and/or anticoagulant therapy. In contrast, acute subdural and extradural hematomas are often observed in young people with traumatic brain injury. The coexistence of ipsilateral chronic subdural and extradural hematomas is rare. Depending on the Glasgow Coma Scale and neuroimaging findings, early surgical intervention is mandatory, as seen in our patient. Early surgical evacuation of a traumatic extradural and chronic subdural hematoma should be done. Also, antithrombotic drug use can lead to chronic subdural hematoma.

Surgical techniques for evacuation of chronic subdural hematoma: a mini-review

Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.

Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

BACKGROUND

The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied.

OBJECTIVE

To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management.

METHODS

Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach.

RESULTS

Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventional management, respectively. MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR = 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR = 0.78 [0.449-1.25], P = .31), mortality (RR = 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = -0.57 [-2.55, 1.41], P = .57). For MMA embolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes.

CONCLUSION

MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.

Short-term follow-up pilot study of sole middle meningeal artery embolization for chronic subdural hematoma: influence of internal architecture on the radiological outcomes

PURPOSE

To identify prognostic factors with emphasis on chronic subdural hematoma (CSDH) architecture that determines short-term outcome of middle meningeal artery embolization (MMAE).

METHODS

Consecutive CSDH patients treated by MMAE (November 2019 and March 2022) were retrospectively analyzed. Four architectures were analyzed: homogeneous, laminar, separated, and trabecular types. Predictor variables from baseline CT were correlated with radiological endpoint (≥ 50% of hematoma volume reduction), time to reach the endpoint, and rate of volume reduction.

RESULTS

Study included 50 patients with 56 CSDHs (median age [first quartile, Q1; third quartile, Q3] 70.5 [60, 78.3] years; 36 were men). Separated type reached the endpoint at a lower rate on both bivariate (p = 0.02) and multivariate Cox model (0.034). Kaplan-Meier curves demonstrated that the median [Q1, Q3] time for 50% of the hematomas to reach the endpoint was 5 [4, 8], 4 [3, 5], 15 [15, 15], and 11 [4, 19] weeks for homogeneous, laminar, separated, and trabecular types, respectively. Linear mixed-effect model demonstrated a significant variation in the slope of hematoma volume reduction that was - 4.16 (95% confidence interval [CI] - 5.4, - 2.9), - 6.7 (95% CI - 8.35, - 5.1), - 2.03 (95% CI - 4.14, 0.08), and - 5.06 (95% CI - 6.8, - 3.32) ml per week for homogeneous, laminar, separated, and trabecular subtypes, respectively.

CONCLUSION

Separated CSDH is a poor prognostic type in achieving radiological endpoint and a slower rate of volume reduction. While, homogeneous and laminar types reached the endpoint faster than separated and trabecular types on short-term follow-up.

Seizure after chronic subdural hematoma evacuation: associated factors and effect on clinical outcome

Objective

Chronic subdural hematoma (CSDH) is a common disease in neurosurgery, which usually occurs in the elderly. Seizure is one of the postoperative complications in CSDH patients and can affect patient outcomes. There is currently no consensus on whether antiepileptic drugs should be prescribed prophylactically. The aim of this study was to evaluate independent risk factors for postoperative seizures and unfavorable outcomes in CSDH patients.

Methods

We reviewed 1,244 CSDH patients who had undergone burr-hole craniotomy in this study. Patient clinical data, CT scan results, recurrence and outcome data were collected. We divided the patients into two groups based on whether they had a postoperative seizure. Percentages and χ² tests were applied for categorical variables. Standard deviations and two-sided unpaired t-tests were applied for continuous variables. Stepwise logistic regression analyses were performed to identify the independent factors of postoperative seizures and unfavorable outcomes.

Results

The incidence of seizures after CSDH surgery was 4.2% in this study. There was no significant difference in recurrence rate between seizure and non-seizure patients (p = 0.948), and the outcome of seizure patients was significantly poor (p < 0.001). There are more postoperative complications in seizure patients (p < 0.001). Logistic regression analysis showed that the independent risk factors for postoperative seizures included drinking history (p = 0.031), cardiac disease (p = 0.037), brain infarction (p = 0.001) and trabecular hematoma (p < 0.001). The use of urokinase is a protective factor for postoperative seizures (p = 0.028). Hypertension is an independent risk factor for unfavorable outcome in seizure patients (p = 0.038).

Conclusion

Seizures after CSDH surgery were associated with postoperative complications, higher mortality and poorer clinical outcomes at follow-up. We believe that alcohol consumption, cardiac disease, brain infarction and trabecular hematoma are independent risk factors for seizures. The use of urokinase is a protective factor against seizures. Patients with postoperative seizures need more stringent management of their blood pressure. A prospective randomized study is necessary to determine which subgroups of CSDH patients would benefit from antiepileptic drugs prophylaxis.

Artificial cerebrospinal fluid use during burr-hole surgery and reoperation rate in patients with chronic subdural hematoma: an analysis using a nationwide inpatient database

BACKGROUND

The optimal surgical procedure to reduce the recurrence rate of chronic subdural hematoma (CSDH) after burr-hole surgery remains to be established. This study aimed to investigate the association between artificial cerebrospinal fluid (ACF) use during burr-hole surgery and reoperation rate in patients with CSDH.

METHOD

In this retrospective cohort study, we used the Japanese Diagnostic Procedure Combination inpatient database. We identified patients aged 40-90 years who were hospitalized for CSDH and had undergone burr-hole surgery within 2 days of admission, between July 1, 2010 and March 31, 2019. We performed a one-to-one propensity score-matched analysis to compare the outcomes between patients with and without ACF irrigation during burr-hole surgery. The primary outcome was reoperation within 1 year of surgery. The secondary outcome was the total hospitalization costs.

RESULTS

Of the 149,543 patients with CSDH from 1100 hospitals, ACF was used in 32,748 patients (21.9%). Propensity score matching created highly balanced 13,894 matched pairs. In the matched patients, the reoperation rate was significantly lower in the ACF users than that in the non-users group (6.3% vs. 7.0%, P = 0.015), with a risk difference of -0.8% (95% confidence interval, -1.5 to -0.2). There was no significant difference in the total hospitalization costs between the two groups (5079 vs. 5042 US dollars, P = 0.330).

CONCLUSIONS

ACF use during burr-hole surgery may be associated with lower reoperation rate in patients with CSDH.

Pilot Biomarker Analysis and Decision Tree Algorithm Modeling of Patients with Chronic Subdural Hematomas

The elderly population are at high risk for developing chronic subdural hematoma (cSDH). Surgical evacuation of cSDH is one of the most common procedures performed in neurosurgery. The present study aims to identify potential inflammatory biomarkers associated with its development and recurrence. Patients (>65 years of age) who presented with symptomatic cSDH (≥1 cm thickness or ≥5 mm midline shift [MLS]), requiring surgical intervention, were prospectively enrolled. The collected cSDH fluid was analyzed for inflammatory markers. Computed tomography (CT) scan data included pre-operative cSDH thickness and MLS. Outcome data included Glasgow Outcome Scale-Extended (GOS-E) score at 3, 6, and 12 months post-surgery, as well as cSDH recurrence. A decision tree model was used to determine the predictive power of extracted analytes for MLS, cSDH thickness, and recurrence. This pilot study includes 20 enrolled patients (mean age 77.9 ± 7.4 years and 85% falls). Rate of cSDH recurrence was 42%, with 21% requiring reoperation. Chemokine (C-X-C motif) ligand 9 (CXCL9) concentrations correlated with cSDH thickness (r = 0.975, p = 0.040). Interleukin (IL)-6 and vascular endothelial growth factor (VEGF)-A concentrations correlated with MLS (r = 0.974, p = 0.005; r = 0.472, p = 0.036, respectively). IL-5 concentrations correlated with more favorable GOS-E scores at 3, 6, and 12 months (r = 0.639, p = 0.006; r = 0.727, p = 0.003; r = 0.693, p = 0.026, respectively). Regulated on activation, normal T-cell expressed and secreted (RANTES) concentrations correlated with complete cSDH resolution (r = 0.514, p = 0.021). The decision tree model identified that higher concentrations of CXCL9 were predictive of MLS (risk ratio [RR] = 12.0), higher concentrations of IL-5 were predictive of cSDH thickness (RR = 4.5), and lower concentrations of RANTES were predictive of cSDH recurrence (RR = 2.2). CXCL9, IL-6, VEGF, IL-5, and RANTES are associated with recurrence after surgery and may be potential biomarkers for predicting cSDH recurrence and neurological outcomes.

Neutrophil to Lymphocyte Ratio as a Predictor of Postoperative Outcomes in Traumatic Brain Injury: A Systematic Review and Meta-Analysis

(1) Introduction: Traumatic brain injury (TBI) is a leading cause of injury and mortality worldwide, carrying an estimated cost of $38 billion in the United States alone. Neutrophil to lymphocyte ratio (NLR) has been investigated as a standardized biomarker that can be used to predict outcomes of TBI. The aim of this review was to determine the prognostic utility of NLR among patients admitted for TBI. (2) Methods: A literature search was conducted in PubMed, Scopus, and Web of Science in November 2022 to retrieve articles regarding the use of neutrophil to lymphocyte ratio (NLR) as a prognostic measure in traumatic brain injury (TBI) patients. Inclusion criteria included studies reporting outcomes of TBI patients with associated NLR values. Exclusion criteria were studies reporting only non-primary data, those insufficiently disaggregated to extract NLR data, and non-English or cadaveric studies. The Newcastle-Ottawa Scale was utilized to assess for the presence of bias in included studies. (3) Results: Following the final study selection 19 articles were included for quantitative and qualitative analysis. The average age was 46.25 years. Of the 7750 patients, 73% were male. Average GCS at presentation was 10.51. There was no significant difference in the NLR between surgical vs. non-surgical cohorts (SMD 2.41 95% CI −1.82 to 6.63, p = 0.264). There was no significant difference in the NLR between bleeding vs. non-bleeding cohorts (SMD 4.84 95% CI −0.26 to 9.93, p = 0.0627). There was a significant increase in the NLR between favorable vs. non-favorable cohorts (SMD 1.31 95% CI 0.33 to 2.29, p = 0.0090). (4) Conclusions: Our study found that NLR was only significantly predictive for adverse outcomes in TBI patients and not surgical treatment or intracranial hemorrhage, making it nonetheless an affordable alternative for physicians to assess patient prognosis.

A prospective randomized controlled trial of the effect of the number of burr hole on chronic subdural hematoma recurrence: An institutional experience

OBJECTIVE

The purpose of this study was to compare the effect of single burr hole (SBH) versus double burr hole (DBH) drainage on the recurrence rate of chronic subdural hematoma (CSDH).

METHOD

Forty-four patients undergoing burr hole craniostomy (BHC) between July 2022 and December 2022 were enrolled in a randomized clinical trial (RCT) comparing SBH to DBH surgeries. The primary endpoint of this study was the recurrence rate of CSDH. Radiological characteristics such as midline shift, thickness, volume, density, type of hematoma, brain atrophy and so on were secondary endpoints.

RESULTS

Forty-four patients participated in this study. Twenty-two hematomas underwent SBH craniostomy, and the other 22 had DBH craniostomy. The mean age in the SBH and DBH groups were 68.59 ± 7.94 and 69.54 ± 10.58, respectively. In each group, the proportion of males (SBH=16; DBH=15) was higher than that of females (SBH=6; DBH=7). The mean surgery time in the SBH group was significantly less than in the DBH group (p = 0.001). However, the two groups had no statistically significant difference in the CSDH recurrence rate (p = 0.312).

CONCLUSION

Our findings showed that SBH craniostomy is equally effective as DBH craniostomy at draining hematomas and does not increase the recurrence rate. Contrarily, the SBH craniostomy had a shorter surgical duration than the DBH craniostomy. As a result, we recommend SBH surgeries for all patients, with emphasis on the elderly and those with severe comorbidities, as well as in situations with few surgical facilities and a high patient admission rate.

Comparison of Two Drainage Systems on Chronic Subdural Hematoma Recurrence

BACKGROUND

 Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage, especially among the elderly, with a recurrence rate as high as 33%. Little is known about the best type of drainage system and its relationship with recurrence. In this study, we compare the use of two drainage systems on the recurrence rate of CSDH.

METHODS

 We retrospectively analyzed the charts of 172 CSDH patients treated with bedside twist drill craniostomy (TDC) and subdural drain insertion. Patients were divided into two groups: group A (n = 123) received a pediatric size nasogastric tube [NGT]), whereas group B (n = 49) had a drain commonly used for external ventricular drainage (EVD). Various demographic and radiologic data were collected. Our main outcome was recurrence, defined as symptomatic re-accumulation of hematoma on the previously operated side within 3 months.

RESULTS

 In all, 212 cases of CSDH were treated in 172 patients. The majority of patients were male (78%) and had a history of previous head trauma (73%). Seventeen cases had recurrence, 11 in group A and 6 in group B. The use of antiplatelet and anticoagulation agents was associated with recurrence (p = 0.038 and 0.05, respectively). There was no difference between both groups in terms of recurrence (odds ratio [OR] = 1.42; 95% confidence interval [CI]: 0.49-4.08; p = 0.573).

CONCLUSION

 CSDH is a common disease with a high rate of recurrence. Although using a drain postoperatively has shown to reduce the incidence of recurrence, little is known about the best type of drain to use. Our analysis showed no difference in the recurrence rate between using the pediatric size NGT and the EVD catheter post-TDC.

The Short-Term Outcome of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma with Mild Symptom: Case Series

OBJECTIVE

A few reports have demonstrated the efficacy of middle meningeal artery embolization (MMAE) alone for mildly symptomatic chronic subdural hematoma (CSDH); however, the clinical course in the early posttreatment period remains unclear. The purpose of this study was to analyze the short-term outcomes of this technique at our center.

METHODS

This study was based on a retrospective analysis of a single-center consecutive case series. Patients with mildly symptomatic CSDH treated with MMAE alone between July 2020 and June 2022 were examined. Neurological examinations and head computed tomography scans were performed before treatment and 1, 7, 14, and 28 days after treatment. The clinical course of the patients was analyzed. In particular, symptom improvement within 1 week from treatment or rescue evacuation and the factors associated were evaluated.

RESULTS

Fifteen patients were included in this study. No procedure-related complications occurred. Partial or complete recovery within the first week from treatment was observed in 10 cases (66.7%), and the symptoms resolved completely in a median of 26 (6.5-33.5) days. Rescue evacuation was needed in 3 cases (20.0%). The hematoma volume and midline shift gradually decreased from baseline, with a significant improvement within the first week (P = 0.030 and 0.0032, respectively).

CONCLUSIONS

MMAE alone provides relatively early improvement in cases of mildly symptomatic CSDH and may be a potential alternative to surgical evacuation or medical therapy.

Nutritional and inflammatory peripheral blood markers for risk assessment of chronic subdural hematoma: a case-control study

BACKGROUND

Some peripheral blood markers have been demonstrated to be correlated with the re-formation of chronic subdural hematoma (CSDH). The aim of this study was to identify the correlation between nutritional/inflammatory peripheral blood markers and CSDH.

METHODS

188 CSDH patients and 188 age-matched healthy controls were included in this research. The clinical characteristics and peripheral blood markers associated with nutritional or inflammatory status were obtained and analyzed. Conditional logistic regression analysis was applied to identify the potential CSDH risk factors. All the participants were divided into 3 groups based on the tertiles of change in risk factors. The Cochran-Armitage test and one way ANOVA were applied to identify the association between baseline characteristics and independent risk factors. Moreover, the net reclassification index (NRI) and integrated discrimination index (IDI) were calculated to evaluate the improvement in model performance after adding the independent risk factors in the conventional model.

RESULTS

The logistic regression analysis demonstrated that the increased albumin (OR, 0.615; 95 %CI,0.489-0.773; P < 0.001) and lymphocyte count (OR, 0.141; 95 %CI,0.025-0.796; P = 0.027) were associated with lower risk of CSDH. Moreover, addition of albumin and lymphocyte to conventional risk factors significantly improved the risk prediction of CSDH(NRI: 46.47 %, P < 0.001; IDI: 30.92 %, P < 0.001; NRI: 22.45 %, P = 0.027; IDI: 1.23 %, P = 0.037, respectively) CONCLUSION: The decreased albumin and lymphocyte levels were correlated with a high risk of chronic subdural hematoma. The nutritional and inflammatory serum markers should be put great attention because these markers may play roles in finding the cause of CSDH and predicting its risk.

Adjuvant oral tranexamic acid and reoperation after burr hole surgery in patients with chronic subdural hematoma: propensity score-matched analysis using a nationwide inpatient database

OBJECTIVE

Adjuvant medical treatment to reduce the recurrence rate after burr hole surgery for chronic subdural hematoma (CSDH) has not yet been established. This study aimed to investigate the association between tranexamic acid (TXA) use after burr hole surgery and the reoperation rate in patients with CSDH.

METHODS

This observational study used the Japanese Diagnostic Procedure Combination inpatient database, a nationwide inpatient database in Japan, from July 1, 2010, to March 31, 2019. The authors identified patients who were hospitalized for CSDH and underwent burr hole surgery within 2 days of admission. The primary outcome measure was reoperation within 1 year after surgery. One-to-one propensity score-matched analysis was performed to compare the outcomes between patients who started oral TXA within 2 days after surgery (TXA users) and those who did not (TXA nonusers). Robustness of the analyses was assessed using the instrumental variable analysis.

RESULTS

Of the 149,543 patients with CSDH treated at 1100 hospitals, 7366 (4.9%) were TXA users. Propensity score matching created 6564 matched pairs with highly balanced baseline characteristics. The reoperation rate was significantly lower in TXA users than in nonusers (1.9% vs 6.1%, p < 0.001) with a risk difference of -4.1% (95% CI -4.8% to -3.4%). There was no significant difference in composite adverse events (0.6% vs 0.5%, p = 0.817). Total hospitalization costs were also significantly lower in TXA users than in nonusers ($5229 vs $5344 [USD], p < 0.001). The results of the instrumental variable analysis were consistent with those of the propensity score-matched analysis.

CONCLUSIONS

Findings of this study, using a nationwide inpatient database, suggest that adjuvant TXA use after burr hole surgery was associated with a reduced reoperation rate in patients with CSDH.

Dual-energy CT imaging of chronic subdural hematoma membranes: technical note

This technical note describes a novel dual-energy CT (DECT) protocol with iodine map reconstruction that will enable visualization of chronic subdural hematoma (CSDH) membranes. We describe the technique and discuss the potential implications for surgical management. The cohort included 36 patients with 50 hematomas. Enhancing external membrane was demonstrated in all the 50 hematomas, incomplete internal membrane in 13, and complete internal membrane in 23 hematomas. A spandrel sign at the transition zone that indicates partial or complete formation of internal membrane was demonstrated in 36 hematomas. KEY POINTS: • Iodine maps from 5-min delayed post-contrast DECT provide spectral contrast difference and facilitate segregation of chronic subdural hematoma membranes. • The ability to image the membranes helps in assessing the degree of organization of the hematoma by providing the information about the membrane thickness, volume, complexity of the membranes, and the proportion of the liquefied component within the hematoma before surgical procedures are undertaken. • Membrane visualization helps in the localization of the transition zone and extension of the membranes over the cerebral lobes helping in the determination of craniotomy location and size, during membranectomy.